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STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER OYti ~DLAC-er
ADDRESS ~SUBDIVISION / CSM# aAJI,4 p LOT #
SECTION T 3/ N-R W, Town of S7 a'^
'2>2. 31. 1 $ . s 41 r
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
t SHOW i\VERYTHING WITHIN 100 FEET OF SYSTEM
LO
w
S
INDICATE NORTH ARROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
BENCHMARK: Oy ( dl!►'1I~~ h o S~~l k-Q Q
ALTERNATE BM:
SEPTIC TANK / FORMATION
Manufacturer: Lljp~..~.. Liquid Capacity:
Setback from: Well House 1 Other
P u acturer Model# Size
Float sgperation-- Gallons/cycle:
Ah
:SOIL ABSORPTION SYSTEM
Width: S ' Length so Number of trenches ~
1 ~
Distance & Direction to nearest prop. line: L4j~
Setback from: well: t House a5 Other _
ELEVATIONS
Building Sewer Af ST Inlet, ST outlet
PC inlet PC bottom Pump GOff ~7
Header/Manifold ? 3 . Bottom of system t
Existing Grade 7, Final grade 9 2°
DATE OF INSTALLATION:
PLUMBER ON JOB:
L-0, A-
LICENSE NUMBER: /53
INSPECTOR:
3/93:jt
L sc~'r~s~i~ artrTSic t `In~i IRIE 32.3flR A15E4j[VAPfyS " 2, HWY. A. -
Safety Human Relations INSPECTION REPORT
Safety fety and Buildings Division
" (ATTACH TO PERMIT) sanitary ermit o.:
GENERAL INFORMATION
Permit Holder's Name: ❑ City ❑ Village [Town of: State Plan ID No.:
CT M PRAIRIE
Insp. BM Elev.: BM Description: Parcel Tax No.:
TANK INFORMATION ELEVATION DATA A9300059
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark
Dosi ng
Aeration Bldg. Sewer
Holding St/ Ht Inlet
TANK SETBACK INFORMATION St/Ht Outlet
TANK TO P/ L WELL BLDG. AirI to ntake ROAD Dt Inlet
Air I
Septic NA Dt Bottom
Dosing NA Header / Man.
Aeration NA Dist. Pipe
Holding Bot. System
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand
Model Number GPM
Friction Syestem TDH Ft
TDH Lift
Ioss
Forcemain Length Dia. FFii Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS DIMENSIONS
SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manufacturer:
SETBACK
INFORMATION TypeO CHAMBER Model Number:
System: OR UNIT
DISTRIBUTION SYSTEM
Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
Length Dia Length Dia. Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched
Bed /Trench Center Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: STAR PRAIRIE 32.31.18.541F,SW,SW, LOT 2, HWY. 64
Plan revision required? ❑ Yes ❑ No Us
e other side for additional information. lovlq~~-l SBD-6710 (R 05/91) Date Inspector's Signature Cert No.
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER: ,
T
DILHR SANITARY PERMIT APPLICATION
In accord with ILHR 83.05, Wis. Adm. Code COUNTY
.j'f, r, 01~
STATE SANITARY PEFIMIT
-Attach complete plans (to the county copy only) for the system, on paper not less than ❑
8% x 11 inches in size.
ec i ision to previous application
-See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER
1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION.
PROPERTY OWNE PROPERTY LOCATION
Or oLkLAi er SW%4_50%,S 3.7 TN,R for)
PROPERTY OWNER'S MAILING; ADDRESS LOT # ^ BLOCK #
/ 7 6 q T. aq
CITY, ST AXE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
W- VI 01 -af~ L-OtC2 Q -51q 5 P
II. TYPE OF BUILDING: (Check one) ❑ State Owned ❑ VILLLL.AGE DD NEAREST ROAD
SfA~lraJ~r~o
❑ Public 1 or 2 Fam. Dwelling-# of bedrooms 14 =N •
PARCEL TAX NUMBER( S)
111. BUILDING USE: (If building type is public, check all that apply) a 3 8 _/1 3 a - (00 60
1 ❑ Apt/Condo
2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility
3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining
40 Church/School 8 ❑ Mobile Home Park 120 Service Station/Car Wash
5 ❑ Hotel/Motel 9 ❑ Office/Factory 130 Other: Specify
IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable)
A) 1. M New 2. ❑ Replacement 3.E1 Replacement of 4. ❑ Reconnection of 5.0 Repair of an
System System Tank Only Existing System Existing System
B) ❑ A Sanitary Permit was previously issued. Permit - Date Issued
V. TYPE OF SYSTEM: (Check only one)
Non-Pressurized Distribution Pressurized Distribution Experimental Other
11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12 ® Seepage Trench 220 In-Ground 42 ❑ Pit Privy
13 ❑ Seepage Pit Pressure 430 Vault Privy
14 ❑ System-In-Fill
VI. ABSORPTION SYSTEM INFORMATION:
1. GALLONS PER DAY 2. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE
L7/~O REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) (3~ ELEVATION
' 4 9S Pr 1 -5 4D • / ~ j 0 Zy Feet 1.5 71 Feet
CAPACITY
VII. TANK Site
in allons Total # of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper.
INFORMATION New xistin Gallons Tanks Concrete glass App.
Tanks Tanks structed
Septic Tank or Holdin Tank Q {5 PI^
Lift Pump Tank/Si hon Chamber
VIII. RESPONSIBILITY STATEMENT
1, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name (Priqt~ Plumber's Signat bN(No Stamps) MP/MPRSW No.: Business Phone Number:
C a) ki I r VL'$ W*- r-S /.S lcz3 /,s' a sib -.S/435'
Plumber's Address (Street, City, Sit te, Zip Code):
IX. CO tjNTYIDEPARTMENT USE ONLY
E] Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issuing A nt Si N m
Approved ❑ Owner Given Initial Surcharge Fee)
Adverse Determination X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
( SBD-6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety A Buildings Division, Owner, Plumber
INSTRUCTIONS
1. -A-sanitary permit is valid for two (2) years.
2. Your sa-nitary,permit may be renewed before the expiration date, and at the time of renewal any new
criteria in the Wisconsin Administrative Code will be applicable.
3. All revisions to this permit must be approved by the permit issuing authority.
4. Changes in ownership or plumber requires a Sanitary Permit Transfer/Renewal Form (SBD 8349) to be
sub tted to the f o.rnty prior to installation.
5. Or s sewage syst~4+'r~s must be properly r~•tr;ntain`ed. The slept=c tank(s) must be purirpe(j i5y a rcensed;
Yumper,whene er necessary, usually Vvery 2 to 3 years.
6. If you\have questions concerning your onsite sewage-system, contact your local code administrator or th'e
State of Wisconsin, Safety & Buildings Divisign, 60$-266-3815..
To bg. complete and accurate thti sanitary permit application must include:
1. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of
where the system is-to be installed.
a
II. Type of building being served' Check only one- an d- complete of bedrooms if 1 or 2 Family Dwelling.
III. Building use. If building type is Public, check all appropriate boxes that apply.
IV. Type of permit. Check only one in line A. Complete line B if permit is for tank replacement, reconnection, or
repair.
V. Type of system. Check appropriate box depending on system type.
VI. Absorption system information. Provide all information requested in ##1-7.
V! 1. Tank Lnfirmation Fill in the capacity or ;ary new and/or - xisifirig tank. list the total g&ll&-1s,, number of
tanks and r ! nufactu-er's name. Indicate prefab or site wostructed and tank material. CcmalF^te fir all ,
septic, pu+ -.`ziiphon and holding tanks for this system. Chi:,ck experimerizai rpproval cr.ly G tank: received
exPori r~~ a! product approval from D10-0.
Vill. Responsitwity statement. Installing plumber is to fill in nar-re, 'sieer+se number with apprar~f' z:7 to prefix (e.g.
MP, etc,), address and phone number. Plumber must sign application form.
IX County/ Department Use Only.
X County/Department Use Only.
Corjp:et(, r.lans arid specifications. riot smaller than 8'/2 x !riches must be submitted to tl"e county. The
plans Fula iorJude the following: A) pint plan, drawn to with comple to c ne,,--Jors !o;::at~on of
hr~'d,rr, y r,~~`s), sp ,t` tank(s) or o-ler• treatment tanks, .-;;',-c wer- we! ~3; wns,_. „rain; w-=iter service;
strejjry-,t :joo ia~es, pomp or siphon ranks; distribution box-s, -:t„l ?t,)S- ption svsterris, relrl;=cement system
areas, .:nci location of the bui'dir,g st-ved, B) hoiizon,t.. .ertical ~le~ation reference points;
C) cornpICA0 specifications for pumps and controls; dose v:--lum elevation differences; fr c,,.on loss; pump
performarie urge; pump model and pump manufacturer; D) cross section of the soil absorption system if.~
required by°fhe county; E) soil test data on a 1,15-form; and F),'all aizing information.
- - - - - - - - - - - - - - - - - - -
GRAUNbWA►TER SURCHARGE
1983 Wisconsin Act 410 included the creation of surcharges (fees) fora number of
regulated practices which oar effect groundwater.
The monies cof:ected through`these'surcharges are used for_monitgrinu groundwater, gri,und
water contarnination investigations and establishnfer i ,.t . ar.-;ards,
-
SBD-6398 (R.11/88)
APPLICATION FOR SANITARY PERMIT
STC-100
This application form is to be completed in full and signed by the owner(s) of
the property being developed. Any inadequacies will only result in delays of
the permit issuance. Should this development be intended for resale by
owner/contractor,(spec house), then a second form should be retained and
completed when the property is sold and submitted to this office with the
appropriate deed recording.
Owner of property : 4s o m B o wc~ e r-
Location of property (.v 1/4 S 1/9, Section 3 , T LN-R~W
Township ~~`~-t r ~r-a r
Mailing address / 7~ y 95
4kk) lfzc~ m 8nd W i XV.017
Address of site
Subdivision name ~ri e'/l o---i (IOW ~A9•/~/(c9
Lot number o2
Previous owner of property J . F A
Total size of parcel A eo r
Date parcel was created
Are all corners and lot lines identifiable? Yes No
Is this property being developed for resale (spec house)? Yes 0
Volume C//09 and Page Number c~0 8 as recorded with the Register of Deeds.
---j------=--------------- --'-0
INCLUDE WITH THIS APPLICATION THE FOLLOWING:
A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE NUMBER, and
the SEAL OF THE REGISTER OF DEEDS. In addition, a certified survey, if
available, would be helpful so as to avoid delays of the reviewing process. If
the deed description references to a Certified Survey Map, the Certified Survey
Map shall also be required.
7
PROPERTY OWNER CERTIFICATION
I(We) certify that all statements on this form are true to the best of my (our)
knowledge; that I (we) am (are) the owner(s) of- the property described in
this information form, by virtue of a warrantVMWOpf ded i n the Office of
the County Register of Deeds as Document No. ; and that I (We)
presently own the proposed site for the sewage disposal system (or I (we) have
obtained an easement, to run with the above described property, for the
construction of said system, and the same has been duly recorded in the Office
of the C ty Register of Deeds, as Document No.
S nature of 0 Signature of Co-Owner (If Applicable)
Dat of Signature Date of Signature
r
THIS .e x~e.- r.H oA;+ '
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Be~viell G. Jar sen and Xatn' r.ri M. Jan,. n, ~ 4:,
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the following &,sciibed real e3tate in ..._.St.._Croix County,
State of Wi,cona:n:
Tax Par,-et Rio:
i Part of Sk of &4% of Section 32, Ub }AT) 31- i,~_)rth, e 13 St;. CvOIx
County, Wisconsin described as follovra; Lot 2 of Certafi- )1 Survey Ylp filed
Septerb-r 18, 19814 in Vol. "5", Pa&-e 14069.
FEE
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This 1S i10t - homestead property.
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(is) (is not)
Exception to warranties: easerrents, re-str'ictions and rights-0f-':,"ay of moot-d, if any
41.1
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g Dated this - - day o. - -
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..._Bert ll_G._Jansen ' --.Kttr>_ieen M. Ja.:{ Pn._ _ r.
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A?1°3'H 9NTICAT10N A C K ?+10WL,E DG ENT
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THIS iNSPKUmEN'i WAS '+?+2A TEU BY
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OF THE SW 1/4 ASSUMED TO BEAR S89049'42"E.
APPROVED
unplatted lands owned by others
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SEPTIC TANK MAINTENANCE AGREEMENT 3 x•37,/8 V/ F o
St. Croix County z
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OWNER/BUYER -JSo,,i A rZ c_L-•e.( ~
ROUTE/BOX NUMBER ~ 71a ire Number
CITY/STATE ~~GdYY~'/ lcf~iS 7.IP
PROPERTY LOCATION: 50 14, SW 1L, Section T N, W, I
Town of G-f CLA PSt. Croix County,
Subdivision~S(b'~ Lot number A _
Improper use and maintenance of your septic system could result in
its premature failure to handle wastes. Proper maintenance con-
sists of pumping out the septic tank every three years or sooner,
if needed, by a licensed septic tank pumper. What you put into i
the system can affect the function of the septic tank as a treat-
ment stage in the waste disposal system.
St. Croix County residents may be eligible to receive a grant for
a maximum of 60% of the cost of replacement of a failing system,
which was in operation prior to July 1, 1978. St. Croix County
accepted this program in August of 1980, with the requirement that
owners of all new systems agree to keep their systems properly
maintained.
The property owner agrees to submit to St. Croix County Zoning a
certification form, signed by the owner and by a master plumber,
journeyman plumber, restricted plumber or a licensed pumper veri-
fying that (1) the on-site wastewater disposal system is in proper
operating condition and (2) after inspection and pumping (if nec-
essary), the septic 'tank is less than 1/3 full of sludge and scum.
Certification form will be sent approximately 30 days prior to
three year expiration. H
0
V_
I/WE, the undersigned, have read the above requirements and agree
to maintain the private sewage disposal system in accordance with x
the standards set forth, herein, as set by the Wisconsin Depart- v
ment of Natural Resources. Certification form must be completed
and returned to the St. Croix County Zoning Office within 30 clays
of the three year expiration date.
S I C N E
D A,~~
St. Croix County Zoning Office
P.O. Box 98
Hammond, WI 54015
715-796-223S► or 715-425-8363
Sign, date and return to above address.
DEPARTMENT OF REPORT ON SOIL BORINGS AND % SAFETI ~ B DIVISION
LABOR AND PERCOLATION TESTS (115) P.O. BOX 7969
HUMAN RELATIONS MADISON WI 53707
0163.090) & Chapter 145.045)
LOC'ATION:6 SECTION: W TOWNSHIP/Nildfll try: LO,.7T NO.:BLK. NO. SL .Dll IISSII/ON NAME:
W ~1/ 3Z /T H/R/ (or) ~1 3~~~^^1__ ✓v~~ ~(i~ L)/'r
COUNT OWNERS NAME: MAILIN / DDRESS:
JD. 4
L--~
USE DATES OBSERVATIONS MADE
NO. BEDRMS. COMMERCIAL DESCRiI TION: PROFILE DE1R1I'TIONS: PERCOLATION TESTS:
Residence New ❑Replace , ~ / _ f„2 ~ / C'~
RATING: S= Site suitable for system U- Site unsuitable for system
CONVENTIONAL: M((O~DUND: IN-GROUND RESSU E~SYS E( D S ~M-IN-FILLfiOLDING TANK: RECOMMENDED <SY% M:(o )
S Eu JL~ S ❑U S ❑U ®U ❑ S ®U L C-1
If Per rcolatio ests are NOT required GESIGN RATE: If any portion of the tested area is in the
under s.H63. ,(5)(b), indicate: n J y~. Floodplain, indicate Floodplain elevatio _JI
PROFILE DESCRIPTIONS ~llr_ C' I Z
BORING TOTAL DEPTH T R UNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER BE fH-W. ELEVATION OBSERVED EST. IGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
S 33 z
B- -2 Cl
7 "71(
B- 93 f IUME
33 W7
A) J-3 1, L S. tly-i's
B-
r PERCOLATION TESTS
"s,ma
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER LNZ~-6S AFTERSWELLING INTERVAL-MIN. PERIOD t; D PERIOD PER INCH
P-
.41
P-
P_ i
P-
PLOT PLAN: Show locations of percolation tests, soil borings nd the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori-
zontal and vertical elevation reference points and show their Ic.:ation on the plot plan. Show the surface elevation at all borings and the direction and percent
of land slope. ap)okr
SYSTEM ELEVATION L_4-*, 1
T N_
.
1 _
I
i r
I
4 ~ J
I, the undersigned, hereby certify that the soil tests reported on this form were made by me in acc )rd with the procedures and methods specified in the Wisconsin
Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief.
NAME (print): TESTS WERE COMPLETED ON:
5/-
ADDRESS: / CERTIFICATION NUMBER: PHONE NUMBER (optional):
CST SIGNAT RE
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and ';oil Tester.
DILHR-SBD-C 195 (R. 02/82) - OV _R -
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43-
1 1C 7 S PAGE OF
4416 ~tL vJ Cro c, Sec~ton o A Sys+-e en,
UT- 5 Tb
Fresh Air Inlets And Observation Pipe
u=--Approved Vent Cap
Minimum 12" Above
Final Grade
20- 42" Above Pipe _ 4" Coat Iron
To Final Grade Vent Pipe
Mash Hay or synthetic covering
min. 2' Aggregate
- Over Pipe
Distribution -Tee
Pipe 0 0 0 0
i 6!Agqi*go!o
h piPe
rforated Pipe Below
Bh Pipe
o -Coupling Terminating At
Bottom Of System
Pr~~ose~ ~lflal gre.el<
.SOIL FILL
D1STRIBUTIO1.3 PIPE
APPROVED ~4WPETIC COVER
" o MAT~RIKt- OR 9e OF STRAW
OF 1\66REGATE OR MARS" HAy
- _ e e t 1 r,e8
G7 (ep 0 F.12-2/
p AGGREGATE
V,LEV.. OF-FEET
i 2. ie
4-r-
DIS-1-R113UTIOU PIPE TU BE AT LEAST INCHES BELOW ORIGINAL GRADE
A►JU AT LEAST LO INCHES BUT KIO MORE THAI) 42. IAICIIES BELOW FIfJAL GRADE
MAXIMUM DEPTH OF EXCAVATIOP FROM ORI&INAL WK WILL BE ~ INCHES
MINIMUM W" OF EACAVATION FROM 00KI4IMAL GR49E WILL BE INCHES
S i G fJ E O: ~ ()a-QkAA
LICENSE AIUMBER: /34-3
DATE:'d6 -9 Z
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